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  • Which Diagnostic Test is Best

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    Old 08-15-2003, 11:59 AM   #1
    ilikesleep
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    Post Which Diagnostic Test is Best

    Hi All,
    I know I shouldn't go around second-guessing my endocrinologist but I'm really trying to find out what's wrong with me.
    Here's the deal: I had a 24-hour urine cortisol ordered by my first dr. - it showed a low cortisol level. Second dr. said an a.m. blood test is a better way to determine whether cortisol is low. Took that blood test, everything's normal.
    In your experience, which is the more accurate? test? Should I insist on the stimulation tests?

     
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    Old 08-15-2003, 05:48 PM   #2
    orion
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    Second-guessing doctors should be taught in school because most doctors can't remember 95% of what they learned in medical school. If you have a rare or difficult to diagnose illness, the chances of them finding it are very low. Combine that with the need for doctors to appear god like and you have lots of misdiagnosed patients.

    That said, your doctor is an idiot. You can't, I repeat you can't, diagnose low cortisol by a single blood test. Cortisol is pulsed in 20 minute cycles so if you get a low reading you can't tell whether that is significant or not.

    The 24-hr urine cortisol test is better, because it averages out the highs and lows, but a single day's collection tells you very little because cortisol varies day to day and week to week. So the doctor who did the 24-hr test to see if your cortisol was low is also an idiot.

    So there you have it, two doctors and both are idiots, proving once again that stupid doctors are everywhere. But what is worse, they pretend to know something even when they KNOW they don't.

    Now first, you don't want to know if you have low cortisol, what you want to know is if you have a low cortisol reserve. That means, when your system is stressed can it make sufficient cortisol to satisfy the demand. It turns out, to test this is hard to do because adrenal output is variable AND because no one knows for sure how much is really enough.

    The accepted gold standard to determine cortisol reserve is the insulin induced hypoglycemia test. In this test, they give you a large dose of fast acting insulin to drive your sugar very low. Your body reacts in panic because low sugar endangers your brain, so your body reacts by pumping out pituitary hormones, specifically ATCH which in turn commands your adrenals to produce cortisol. If you have a large increase in cortisol output during the test, you are deemed to have passed the test. If not, then you are adrenal insufficient, even though you might well produce lots of cortisol for every day needs, during critical times you can't produce enough. In practice that translates to feeling well lots of times and pretty horrible during times of stress. This test is expensive and has a risk factor with it so you need a nurse and doctor standing by in case of trouble.

    A less dangerous test is one in which they give you one of several drugs to stimulate your adrenal glands to see if they will react to the stimulation. If they do, then it is judged that you are ok. However, if the source of your adrenal insufficiency is your pituitary, this test will not find it. So you get a false reading saying you are ok, when in fact you are not. Of course, if the tests shows you do have insufficiency, then it saves lots of money and time.

    So there you have it, go find a doctor who knows what he is talking about and tell him you want an ITT test to test your cortisol reserve. He will probably have to race to find his old medical books to find out what in the world you are talking about. Your low 24-hr urine test is suspicious enough to warrent a more expensive test.

    Remember, the doctor works for you, you pay him for advise, he doesn't tell you want to do, you tell him what to do!


     
    Old 08-17-2003, 12:25 AM   #3
    ilikesleep
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    Wow! Thank you so much for your thorough and knowledgeable reply. I suspected my dr was a bit of an idiot, that's why I decided to post. It seems that the drs I've gone to over the years have only pursued the diagnoses that they initially suspect and aren't willing to look beyond that....even if they find nothing and you continue to feel like crap.
    I will respectfully ask my dr. for the insulin stimulation test or find someone who will order it. It seems like it's at least worth looking into!
    Thanks again!

     
    Old 08-17-2003, 07:16 AM   #4
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    There is also the Adrenal Stress Index test (ASI) from DiagnosTechs lab in Washington state. This is a salivary test which assesses cortisol and DHEA at four times in a 24 hour period. It also evaluates secretory IgA to assess immune system status, and gliadin antibody for gluten sensitivity (celiac). Even prestigious Vanderbilt University Medical is now using salivary tests for cortisol levels. My son and I are patients of Clymer Healing Research Center in PA, and this clinic uses the ASI test. They do treat patients at a distance by phone and email once they have had an ASI test. I was originally diagnosed with adrenal insufficiency in 1989 by an MD (family Dr) by way of a cortrosyn stimulation test.
    -Katie

     
    Old 08-17-2003, 10:18 PM   #5
    ilikesleep
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    Hi again,
    Since you folks seem to be more knowledgeable than my drs., I thought I'd just tell you what my "scores" are and see what your assessment is. My 24-hour urine cortisol level was 7 ug/dL. There was no reference range listed. The blood level was 15 ug/dL and reference range was 8-19. Would this make you pursue it further? I suppose I don't have many of the symptoms of addison's but I do have the overwhelming fatigue. Any help you can provide would be greatly appreciated.

     
    Old 08-18-2003, 09:46 AM   #6
    orion
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    Quote:
    Originally posted by ilikesleep:
    My 24-hour urine cortisol level was 7 ug/dL. There was no reference range listed. The blood level was 15 ug/dL and reference range was 8-19.
    Well, the blood level tells you on that day at that moment your adrenal glands appear to be working normally. What it doesn't tell you is how stressed you were. Under stress the adrenal glands can triple output to well over 50. So if you were stressed, 15 is a pretty poor showing, if you were totally relaxed then 15 is good.

    On the other hand the urine reading of 7 is very low compared to the normal reference range of 20-90. Notice the big range allowed, again reflecting stress levels in different people. If I was your doctor I would have repeated both test to be sure the reading made sense. Most likely they would both come back substantially different, because cortisol has a huge variation. If your urine test came back low again, then I would test further. The blood test is really meaningless because cortisol levels vary so much minute to minute.

    If you complained of fatigue, I would first test your thyroid, blood sugar and the standard blood tests for infection, anemia and cell counts etc. If those came back ok, I would check things like testosterone, take a history of the fatigue, limes disease etc. The last thing I would check is adrenal function because it's so hard to figure out. Why did you get a cortisol test in the first place? Have you had the other tests?

    Given the urine reading, I would repeat that test and if it still came back low, then I would push for a provocative test to rule out adrenal problems.

     
    Old 08-23-2003, 11:51 AM   #7
    ilikesleep
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    Once again, you guys rock.
    Basicallly, I've been tested for all of those things you mentioned. The only thing of significance is that I do, indeed, have low blood sugar. However, after years of eating the right things at the right times, I'm feeling no better. In doing some research, I read that low blood sugar can be associated with cortisol problems. That's basically why I pushed for the first test.
    To add an additional wrinkle, since my last post I discovered that my aldosterone (which I understand does not really fluctuate throughout the day) was low. My doc. says this can happen in the absence of cortisol insufficiency but a few things I've read indicate that it rarely happens without the cortisol also being low. Any thoughts wise ones?

     
    Old 08-25-2003, 08:44 PM   #8
    orion
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    Quote:
    Originally posted by ilikesleep:
    To add an additional wrinkle, since my last post I discovered that my aldosterone (which I understand does not really fluctuate throughout the day) was low. My doc. says this can happen in the absence of cortisol insufficiency but a few things I've read indicate that it rarely happens without the cortisol also being low. Any thoughts wise ones?
    Sounds like the beginnings of Addison's disease where your adrenal glands are not working properly and their output is fluctuating sometimes normal sometimes low. You need to test your cortisol reserve with a more provocative test.

     
    Old 08-26-2003, 12:40 PM   #9
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    There've been many threads here about which test is best, and the saliva one seemed to be the consensus.

    Quite a few mention doctors' difficulties diagnosing adrenal insufficiency, having forgotten a lot, and one just tried to snow me because I'm a woman with "Bayes' Theorum" which is an abstract PROBABILITY thing like "Murphy's Law", used in medicine? How scientific is that, I ask you?

    So do insurance companies like Blue Cross pay for your attempts to find a doctor, and sometimes even endocrinologists are inept about this? Some hillbilly without a bit of education expresses jealousy about the attention sick people get, calls them hypochondriacs, not needing their meds, and doctors assume the out-of-line one knows the patient and medicine, agrees, says 95% of his patients are hypochondriacs who "read too much". My mind's made up, don't confuse me with any facts syndrome. How do you find one with some common sense? Female doctors any better?

     
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